Provider Demographics
NPI:1407624554
Name:PACHECO, KELLY (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PACHECO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 SAINT NICHOLAS AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-6568
Mailing Address - Country:US
Mailing Address - Phone:631-877-2879
Mailing Address - Fax:
Practice Address - Street 1:310 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-6566
Practice Address - Country:US
Practice Address - Phone:631-877-2879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL07067100104100000X
NY122634104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker